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UNDERGROUND STORAGE TA*Wk UNAUTHORIZED RELEASE (LEAK)/(,")"NTAMI t ATI.ONyF �PP <br /> EMERGENCY $TATE TANK ID �•.LLi <br /> r 1 HAS STATE OFFICE OF EMERGENCY SERVICES � <br /> U YES ❑ NO REPORT BEEN FILED? ❑ YES ❑ NO O /� I i.0 <br /> REOPO T DATE S --P- LOCAL CASE p REGIONAL BOARD CASE P o F-/ S EPr r-OR I <br /> Ml M D 5D Y Y r [ (} <br /> NAME"OF INDIVIDUAL FILING REPORT PHONE SIGNATURE iJIENTAL EALTH <br /> 'm J h QJ-w OCi L&v o 7S r (4) — 3 <br /> D REPRESENTING ❑ LOCAL AGEN V OTHER COMPANY OR AGENCY NAME <br /> w <br /> O ❑ OWNER/OPERATOR E] REGIONAL BOARDC <br /> W ADDRESS �y 0 <br /> Ili f 1�'} AV.&- <br /> �QS-1 STREET 'fit CITY <br /> f STATE ZIP <br /> I > NAME Ci CONTACT PERSON y�^ PHONE �J�j. <br /> Z' <br /> Ste• li.X -+�VOS(��� -�Y�L ❑ UNKNOWN �yalk \ ',§ IY` O {Vr 70 .y O <br /> o U; <br /> ADDR�\`` Nti� f-�fvJ�.� 'Ca[. <br /> STREET CITY STATE ZIP <br /> FACILITY NAME (IF APPLICAABBLE) OPERATOR PHONE <br /> c ADDRE S <br /> U <br /> JO STREET CITY COUNTY ZIP <br /> W CROSS STREET V <br /> PE OF AREA E:] COMMERCIAL INDUSTRIAL TYPE OF BUSINESS ❑ RETA1�. FUEL STATION t <br /> RESIDENTIAL ❑RURAL ❑OTHER U UNKNOWN OTHER- + <br /> LCOCAL AGENCY AGENCY NAME - CONTACT PERSON PHONE / I /_ <br /> ?� J�= Y.f i1\ C/��� 1< �,�,�'^v r'^ ��✓1� {�Y li-!i ishi <br /> H REGIONAL BOA <br /> zw <br /> Wu <br /> R� co►zQor o <br /> a a TSCD <br /> f <br /> w CAS A (ATTACH EXTRA SHEET IF NEEOED) NAME QUANTITY LOST (GALLONS) <br /> U O t <br /> UNKNOW <br /> F <br /> 00 <br /> tD> <br /> vOi L (2) I 1 n UNKNOW <br /> DATE DISCOVEQREDJ HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE M�O/NITORING,. ty t <br /> j �M !M /D �Y �Y ❑ ROUTINE MONITORING ❑ REMOVAL -�TANK NUISANCE CONDI TIONi !][I OTHER: I&'^' V+ 1 <br /> z /� <br /> ww DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> OW MI MI D D YJ YJ UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK nCLOSE TANK <br /> Oa HAS DISCHARGE BEEN STOPPED? <br /> m IRE PAIR TANK REPAIR PIPING ]CHANGE PROCEDURES 1, <br /> a <br /> YES NO IF YES, DATE I MI MI 01 DI YJ Y ❑OTHER <br /> w SOURCE(S) OF DISCHARGE TANKS ONLY/CAPACITY 1 L.oc:xC> GAL CAUSE(S) <br /> '^ TANK LEAK ❑ UNKNOWN El OVERFILL ❑CORROSION <br /> aAGE ( It I YRS. ❑ UNKNOWN <br /> u <br /> u: PIPING LEAK MATERIAL <br /> RUPTURE/FAILURE r ISPILL <br /> R ❑STEEL (y! FIBERGLASS ��......{/ <br /> 0 : -IOTHEz (SPECIFY) [:]OTHER <br /> RESOURCES <br /> (UNKNOWN _)OTHER <br /> YYY�\\\ <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED THREAT- - a OF <br /> YES N011 THREATENED UNKNOWN VES NO ENCO KNOWN WELLS <br /> PULIC <br /> U AIR (VAPOR) CJ J (:j L-] WABER DRINKING ` -1 } i J <br /> wSOIL (VADOSE ZONE_) ❑ OBJ 1 <br /> aY GROUNDWATER ❑ �� PRIVATE DRINKING t )If <br /> �J( �l �_1 <br /> < WATER iL{JI 7 J <br /> w� SURFACE WATER OR STORM DRAIN C] �� INDUSTRIAL 1 wl ❑ ❑ <br /> (UI- BUILDING OR UTILITY VAULT LJ IDL <br /> ❑ AGRICULTURAL r J 3 f ❑ ❑ <br /> 'O` OTHER (SPECIFY) E1 ❑ 1--] ElOTHER(SPECIFY) ❑ ❑ ❑ i <br /> N 1 <br /> w �I <br /> 5 GROUN WATER BASIN NAME <br /> UNKNOWN <br /> COMMENTS: ) <br /> I- <br /> z <br /> w <br /> f <br /> f <br /> 0 <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED ./SC 05 (10/88) <br />